In The ER: Fatal Overcrowding

ecently, I told my patient, Mr. A, that he was likely to die in front
of me within the next few hours. Not because I, an emergency physician in downtown
Toronto, didnt know what was wrong with him. Not because there was nothing
that we, as doctors, could do for him, but simply because at that moment the Canadian
health care system could not summon the resources to fix Mr. A.

I didnt say it quite like that.

I told Mr. A that the largest artery in his body was bleeding into
his abdomen, that this carried a fifty percent mortality with surgery; a certainty
of death without surgery, and I could not find a vascular surgeon for him.

Both of our hospitals vascular surgeons were operating, we had no Intensive
Care beds free to take care of Mr. A after an operation, even if we
could get him one, and the provincial emergency transfer service, Criticall, searched
desperately but found no available surgeon and bed for my patient in Ontario.
The Criticall coordinator told me, Ive got nothing. Youre on
your own.

Nowadays we, front-line Emergency Medicine providers, are often on our own with
nothing to give a patient. In front of our triage desk, where patients explain
why they have come to hospital, there was once one chair. Then two, then five,
and now there are ten chairs in two rows, filled with those waiting to be triaged.
This is not the waiting room. The waiting room, burst to overflowing, is where
people go to endure their pain along with fifteen to thirty other members of the
public for six, eight, twelve hours with no medical attention after triage. Next
to the triage desk, there are three to six ambulance crews waiting for hours to
deliver their orange-wrapped patients. The Toronto District Ambulance Service
has announced that this offload delay problem is a crisis. They are
frequently unable to respond to emergency calls because they are marooned in hospital
ERs.

It would be nice if we could point to one issue, such as ambulance offload delays,
or packed ER waiting rooms, and say thats the problem  fix that!
The reality is not so simple. These problems are only the highly visible tip of
the iceberg which is health cares now-dysfunctional lack of capacity. During
the past decade, there has been a 40% decrease in inpatient bed funding in Canada.
With an aging population that needs increasingly complex care, the result is that
hospitals are literally overflowing  just check the ambulance parking lot
in front of any Canadian hospital.

It goes like this: The ambulances cannot offload, because the ER beds are full.
The ER is full, because the ER beds are regularly occupied by admitted
patients who are supposed to go to the wards. Across Canada, 10-25% of the wards
beds are filled with patients who need to be placed in rehabilitation, nursing
homes, or palliative care facilities, but there are no places to send them in
the community.

It gets more tricky: Some hospital beds are needed for patients to recover from
elective procedures. If these beds are used for emergency admissions, elective
procedures are cancelled. When elective procedures are canceled, patients
medical problems deteriorate, and they wind up in the ER. Also, the wards are
under intense pressure to discharge patients. If they keep patients too long,
they prevent other patients from coming to the ward from the ER. If they discharge
them too early, the discharged patients quickly become ill again and return to
the ER.

Every day in the ER, patients and families are understandably frustrated by long
waits, either bearing their pain and indignity stoically, or harassing the ER
staff. The ER staff are helpless to assist those who wait politely, and abused
by those who shout at them. The never-ending task of explaining ten times per
hour why there is such a long delay, why an important test cant be performed
yet, or why a patient hasnt had an operation, robs time and energy from
delivering health care, and accelerates the burnout and departure of skilled emergency
nurses and physicians.

Economic pressures and hospital bed closures are the direct cause of the increasing
numbers of patients log-jammed in ERs. Between 1990 and 2000, the number
of acute care beds in Canada fell from 4.0 to 3.3 per 1000 citizens, putting us
well below the OECD average of 3.8 per 100. New Zealand and Germany both have
over twice the number of hospital beds per capita, and we are also bested by France
and Australia. In Ontario, with 2.7 beds per 1000 citizens, bed occupancy jumped
from 85.6% in 1994/95 to 93% in 1999/2000. Hospitals are forced to target occupancy
rates of over 90%. This sounds very efficient, but health care is
an enterprise in which demand for vital services fluctuates wildly and unpredictably.
Studies have demonstrated that occupancy rates above 85% pose discernible risks
to patients, and above 90% a hospital is in a state of regular bed crisis. Running
at high occupancy means that most people will be reasonably cared for most of
the time, but if Mr. A is bleeding to death and there is no capacity
in the system, well you better hope youre not Mr. A.

A convenient political maneuver is to off-load responsibility to the public by
saying ERs are crowded because people are going there inappropriately.
This is false. The vast majority of ER patients are there out of necessity. Why
else would someone wait eight hours to see a doctor? If a fraction of patients
use ERs for problems that could be dealt with elsewhere, they do not clog
the system. Simple problems are quickly dealt with: a physician treats an ankle
sprain in two minutes, or sews up a cut in five minutes, and then the patient
leaves the hospital. In contrast, a patient with chest pain requires a bed, a
cardiac monitor, an intravenous, complex assessments and treatments, time-consuming
tests, multiple electrocardiograms, and a high level of observation for hours
or days. Each patient in the ER waiting to go to the ward, results in 2-4 patients
per hour being stuck in the waiting room. Meanwhile, to discourage people from
seeking care because it is their fault that the system is overcrowded
only results in patients not receiving medical care at times when it is crucial
for them to receive it. Patients often dont know whether their problems
are minor or major  thats why we have doctors to sort that out.

Conjuring up the myth of inappropriate use of the system diverts the
discussion from the more difficult real issue, which is the lack of systemic inpatient
capacity. This is an unattractive political and societal problem, because having
more beds means spending more public money, which means collecting more taxes.
Over the past fifteen years, inefficiencies have already been tightly wrung out
of our health care system by cutting administration, axing extra programs,
shifting care to outpatient settings wherever possible, streamlining bulk purchasing
of supplies, de-listing services, and merging or closing hospitals. On a percentage
of GDP basis, Canada spends just over two thirds of what the US spends, and I
might add, still beats the US in life expectancy, infant mortality, and most other
standard measures of health outcome. Canadians are getting good value for money.
Canadian health care is now lean and sleek, or perhaps bordering on starving and
cachectic. At this point, relieving our systems tragic human congestion
means creating more bed capacity, which means spending more taxpayer money. Thats
your money, and theres no squirming out of it.

When I informed our vascular surgeons that no one in the province would be able
to help Mr. A, they rose to the occasion. Somehow, they squeezed Mr.
A into an operating room although they were both in the midst of surgeries.
With no ICU bed available, Mr. A was cared for after his operation
in the surgical recovery room  which borrowed and jerry-rigged the resources
needed to save his life. A few days later, I heard that he made a good recovery.

This is commendable, but disturbing. Our health care is now reliant upon the improvisational
abilities of health care workers, who often lack the basic resources needed to
care for patients. This is wrong. With our health care system in a state of constant
capacity crisis, some will now find that the line between death and life, between
suffering and dignity, is simply whether services are already occupied-to-capacity
when they need them.

Mr. A is not unique. Any ER doctor or nurse can tell you about narrow
misses, patients almost killed by the ongoing shortage of resources, and who survived
by our juggling and conjuring when there was nothing else to do. The same doctors
and nurses can tell you, in hushed tones, about patients like Mr. A
dying in the ambulances, and in the waiting rooms of our very efficient and cost-effective
health care system.